Baseline bone turnover marker levels can predict change in bone mineral density during antiresorptive treatment in osteoporotic patients: the Copenhagen bone turnover marker study

Anti-resorptive osteoporosis treatment might be more effective in patients with high bone turnover. In this registry study including clinical data, high pre-treatment bone turnover measured with biochemical markers was correlated with higher bone mineral density increases. Bone turnover markers may be useful tools to identify patients benefitting most from anti-resorptive treatment.

INTRODUCTION

In randomized, controlled trials of bisphosphonates, high pre-treatment levels of bone turnover markers (BTM) were associated with a larger increase in bone mineral density (BMD). The purpose of this study was to examine this correlation in a real-world setting.

METHODS

In this registry-based cohort study of osteoporosis patients (n = 158) receiving antiresorptive therapy, the association between pre-treatment levels of plasma C-telopeptide of type I Collagen (CTX) and/or N-terminal propeptide of type I procollagen (PINP) and change in bone mineral density (BMD) at lumbar spine, total hip, and femoral neck upon treatment was examined. Patients were grouped according to their pre-treatment BTM levels, defined as values above and below the geometric mean for premenopausal women.

RESULTS

Pre-treatment CTX correlated with annual increase in total hip BMD, where patients with CTX above the geometric mean experienced a larger annual increase in BMD (p = 0.008) than patients with CTX below the geometric mean. The numerical pre-treatment level of CTX showed a similar correlation at all three skeletal sites (total hip (p = 0.03), femoral neck (p = 0.04), and lumbar spine (p = 0.0003)). A similar association was found for PINP where pre-treatment levels of PINP above the geometric mean correlated with a larger annual increase in BMD for total hip (p = 0.02) and lumbar spine (p = 0.006).

CONCLUSION

Measurement of pre-treatment BTM levels predicts osteoporosis patients' response to antiresorptive treatment. Patients with high pre-treatment levels of CTX and/or PINP benefit more from antiresorptive treatment with larger increases in BMD than patients with lower pre-treatment levels.

P11.32.A EGFR expression and non-methylated MGMT predict distant recurrence in glioblastoma patients treated with standard therapy

Background

Infiltrative growth within the central nervous system is hallmark of glioblastoma (GBM) at time of diagnosis. Targeting infiltrative glioma cells by adding chemotherapy to local treatment (surgical resection and radiotherapy) has led to improved tumor control and survival. Still, infiltrative growth is a major factor in therapeutic failure and tumor recurrence is almost inevitable. Herein, we hypothesize that distant recurrence represents a more migratory phenotype and that biomarkers associated with distant recurrence can be used to personalize the treatment. The aim of this study was to identify clinical and molecular factors associated with distance recurrence in glioblastoma patients treated with standard therapy.

Material and Methods

A prospective cohort of consecutive, non-selected GBM patients administered standard therapy as primary treatment between 2005-2020 at Rigshospitalet, Copenhagen, Denmark. Distant recurrence was defined as a new contrast-enhancing tumor lesion outside the radiation field (> 2 cm from the gross tumor volume). Clinical and molecular factors were screened for association with time to distant recurrence (p < 0.30) using univariate analysis. The final model was generated employing multivariate Cox regression analysis to model the association with time to distant recurrence. It was chosen to maintain known prognostic factors in the model and subsequently add significantly associated factors (p < 0.05). Competing risk adjusted analysis were performed with death as a competing risk.

Results

A total of 897 patients were included and at a median follow-up time of 73 (range: 12-198) months, 733 patients were evaluable for recurrence pattern. Out of 733 patients, 146 patients (20%) had distant recurrence. Median time to tumor progression was 7.0 months for patients with a local recurrence and 8.0 months for those with a distant recurrence (p=0.31). The following prognostic factors were not associated with distant recurrence by multivariate analysis: Corticosteroid use (p=0.84), age (p=0.20), multifocal disease (p=0.81), ECOG performance status (p=0.99) and degree of tumor resection (p=0.20). In multivariate analysis, factors independently associated with a higher likelihood of distant recurrence were: Non-methylated promoter of the MGMT gene (HR=1.93; 95% CI: 1.27-2.95; p=0.002) and positive expression of Epidermal Growth Factor Receptor (EGFR) by immunohistochemistry (HR=3.70; 95% CI: 1.61-8.33; p=0.002).

Conclusion

Non-methylated MGMT and positive expression of EGFR were independently associated with a higher likelihood of distant recurrence in GBM patients treated with standard-of-care. These factors, if validated, can be used for risk stratification and to enrich clinical treatment protocols aiming at improved local or distant tumor control.

Study protocol for OptimalTTF-2: enhancing Tumor Treating Fields with skull remodeling surgery for first recurrence glioblastoma: a phase 2, multi-center, randomized, prospective, interventional trial

BACKGROUND

OptimalTTF-2 is a randomized, comparative, multi-center, investigator-initiated, interventional study aiming to test skull remodeling surgery in combination with Tumor Treating Fields therapy (TTFields) and best physicians choice medical oncological therapy for first recurrence in glioblastoma patients. OptimalTTF-2 is a phase 2 trial initiated in November 2020. Skull remodeling surgery consists of five burrholes, each 15 mm in diameter, directly over the tumor resection cavity. Preclinical research indicates that this procedure enhances the effect of Tumor Treating Fields considerably. We recently concluded a phase 1 safety/feasibility trial that indicated improved overall survival and no additional toxicity. This phase 2 trial aims to validate the efficacy of the proposed intervention.

METHODS

The trial is designed as a comparative, 1:1 randomized, minimax two-stage phase 2 with an expected 70 patients to a maximum sample size of 84 patients. After 12-months follow-up of the first 52 patients, an interim futility analysis will be performed. The two trial arms will consist of either a) TTFields therapy combined with best physicians choice oncological treatment (control arm) or b) skull remodeling surgery, TTFields therapy and best practice oncology (interventional arm). Major eligibility criteria include age ≥ 18 years, 1st recurrence of supratentorial glioblastoma, Karnofsky performance score ≥ 70, focal tumor, and lack of significant co-morbidity. Study design aims to detect a 20% increase in overall survival after 12 months (OS12), assuming OS12 = 40% in the control group and OS12 = 60% in the intervention group. Secondary endpoints include hazard rate ratio of overall survival and progression-free survival, objective tumor response rate, quality of life, KPS, steroid dose, and toxicity. Toxicity, objective tumor response rate, and QoL will be assessed every 3rd month. Endpoint data will be collected at the end of the trial, including the occurrence of suspected unexpected serious adverse reactions (SUSARs), unacceptable serious adverse events (SAEs), withdrawal of consent, or loss-to-follow-up.

DISCUSSION

New treatment modalities are highly needed for first recurrence glioblastoma. Our proposed treatment modality of skull remodeling surgery, Tumor Treating Fields, and best practice medical oncological therapy may increase overall survival significantly.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT0422399 , registered 13. January 2020.

Advances in the treatment of portal hypertension in cirrhosis

Non-selective beta-blockers and handling of esophageal varices has been key elements in the treatment of portal hypertension in recent decades. Liver vein catheterization has been essential in diagnosis and monitoring of portal hypertension, but ongoing needs for noninvasive tools has led to research in areas of both biomarkers, and transient elastography, which displays promising results in discerning clinically significant portal hypertension. Novel research into the areas of hepatic stellate cell function and the dynamic components of portal hypertension has revealed promising areas of treatment modalities, targeting intestinal decontamination, angiogenesis, inflammation and oxidative stress. Future studies may reveal if these initiatives lead to developments of new drugs for treatment of portal hypertension.

The macrophage activation marker sCD163 combined with markers of the Enhanced Liver Fibrosis (ELF) score predicts clinically significant portal hypertension in patients with cirrhosis

BACKGROUND

Noninvasive identification of significant portal hypertension in patients with cirrhosis is needed in hepatology practice.

AIM

To investigate whether the combination of sCD163 as a hepatic inflammation marker and the fibrosis markers of the Enhanced Liver Fibrosis score (ELF) can predict portal hypertension in patients with cirrhosis.

METHODS

We measured sCD163 and the ELF components (hyaluronic acid, tissue inhibitor of metalloproteinase-1 and procollagen-III aminopeptide) in two separate cohorts of cirrhosis patients that underwent hepatic vein catheterisation. To test the predictive accuracy we developed a CD163-fibrosis portal hypertension score in an estimation cohort (n = 80) and validated the score in an independent cohort (n = 80). A HVPG ≥10 mmHg was considered clinically significant.

RESULTS

Both sCD163 and the ELF components increased in a stepwise manner with the patients' Child-Pugh score (P < 0.001, all), and also with increasing HVPG (P < 0.001). receiver operator characteristics (ROC) analyses showed that each one of the individual components predicted a HVPG >10 mmHg with AUROC's of approximately 0.80. The combined score optimised by logistic regression analyses improved the AUROC to 0.91 in the estimation cohort and 0.90 in the validation cohort. Furthermore, a high value of the combined score was associated with a high short-term mortality.

CONCLUSIONS

The combination of the macrophage activation marker sCD163 and the fibrosis markers predicted significant portal hypertension in patients with cirrhosis. This score may prove useful for screening purposes and highlights the importance of both the inflammatory and the fibrotic components of cirrhotic portal hypertension.

Circulating Elastin Fragments Are Not Affected by Hepatic, Renal and Hemodynamic Changes, But Reflect Survival in Cirrhosis with TIPS

BACKGROUND AND AIMS

Progressive fibrosis increases hepatic resistance and causes portal hypertension with complications. During progressive fibrosis remodeling and deposition of collagens and elastin occur. Elastin remodeling is crucially involved in fibrosis progression in animal models and human data. This study investigated the association of circulating elastin with the clinical outcome in cirrhotic patients with severe portal hypertension receiving transjugular intrahepatic porto-systemic shunt (TIPS).

METHODS

We analyzed portal and hepatic venous samples of 110 cirrhotic patients obtained at TIPS insertion and 2 weeks later. The circulating levels of elastin fragments (ELM) were determined using specific monoclonal ELISA. The relationship of ELM with clinical short-time follow-up and long-term outcome was investigated.

RESULTS

Circulating levels of ELM showed a gradient across the liver before TIPS with higher levels in the hepatic vein. Interestingly, the circulating ELM levels remained unchanged after TIPS. The circulating levels of ELM in portal and hepatic veins correlated with platelet counts and inversely with serum sodium. Hepatic venous levels of ELM were higher in CHILD C compared to CHILD A and B and were associated with the presence of ascites. Patients with high levels of ELM in the hepatic veins before TIPS showed poorer survival. In multivariate analysis ELM levels in the hepatic veins and MELD were independent predictors of mortality in these patients.

CONCLUSION

This study demonstrated that circulating levels of ELM are not associated with hemodynamic changes, but might reflect fibrosis remodeling and predict survival in patients with severe portal hypertension receiving TIPS independently of MELD.

Systematic review with meta-analysis: the effects of rifaximin in hepatic encephalopathy

BACKGROUND

Rifaximin is recommended for prevention of hepatic encephalopathy (HE). The effects of rifaximin on overt and minimal HE are debated.

AIM

To perform a systematic review and meta-analysis of randomised controlled trials (RCTs) on rifaximin for HE.

METHODS

We performed electronic and manual searches, gathered information from the U.S. Food and Drug Administration Home Page, and obtained unpublished information on trial design and outcome measures from authors and pharmaceutical companies. Meta-analyses were performed and results presented as risk ratios (RR) with 95% confidence intervals (CI) and the number needed to treat. Subgroup, sensitivity, regression and sequential analyses were performed to evaluate the risk of bias and sources of heterogeneity.

RESULTS

We included 19 RCTs with 1370 patients. Outcomes were recalculated based on unpublished information of 11 trials. Overall, rifaximin had a beneficial effect on secondary prevention of HE (RR: 1.32; 95% CI 1.06-1.65), but not in a sensitivity analysis on rifaximin after TIPSS (RR: 1.27; 95% CI 1.00-1.53). Rifaximin increased the proportion of patients who recovered from HE (RR: 0.59; 95% CI: 0.46-0.76) and reduced mortality (RR: 0.68, 95% CI 0.48-0.97). The results were robust to adjustments for bias control. No small study effects were identified. The sequential analyses only confirmed the results of the analysis on HE recovery.

CONCLUSIONS

Rifaximin has a beneficial effect on hepatic encephalopathy and may reduce mortality. The combined evidence suggests that rifaximin may be considered in the evidence-based management of hepatic encephalopathy.

Novel serological neo-epitope markers of extracellular matrix proteins for the detection of portal hypertension

BACKGROUND

The hepatic venous pressure gradient (HVPG) is an invasive, but important diagnostic and prognostic marker in cirrhosis with portal hypertension (PHT). During cirrhosis, remodelling of fibrotic tissue by matrix metalloproteinases (MMPs) is a permanent process generating small fragments of degraded extracellular matrix (ECM) proteins known as neoepitopes, which are then released into the circulation.

AIM

To investigate their potential as plasma markers for detection of PHT.

METHODS

Ninety-four patients with alcoholic cirrhosis and 20 liver-healthy controls were included. Clinical and laboratory data of the patients were collected. All patients received HVPG measurement with blood sampling. In these samples, the following degradation or formation markers were measured: C1M (type I-collagen), C3M and PRO-C3 (type III collagen), C4M and P4NP 7S (type IV collagen), C5M (type V collagen), C6M (type VI collagen), BGM (biglycan), ELM (elastin), CRPM (CRP).

RESULTS

All ECM markers except for CRPM correlated significantly with HVPG. Interestingly, C4M, C5M and ELM levels were significantly higher in patients with HVPG >10 mmHg. Multiple regression analysis identified PRO-C3, C6M and ELM as significant determinants, while the models A and B including PRO-C3, ELM, C6M and model for end-stage liver disease (MELD) provided better description of PHT (r = 0.75, P < 0.0001). The models provided odds ratios of >100 for having clinical significant PHT.

CONCLUSIONS

These novel non-invasive extracellular matrix markers reflect the degree of liver dysfunction. The different degrees of portal hypertension correlated with these circulating neoepitopes. Using a single blood sample, these neoepitopes in combination with MELD detect the level of portal hypertension.

Effects of training with different interval exercises on horses used for show jumping

Studies examining the effect of conditioning programs to improve the fitness of horses used in show jumping (Show Jumpers) are not available. Therefore, the effects of conditioning with 3 different interval type exercises were examined on 20 Show Jumpers divided into 3 groups matched by age and jumping performance level. Horses participated in 2 conditioning periods (CP) each of 6 weeks separated by 6 weeks without interval exercise. Training during a CP was the same for all horses but for one specific interval type exercise bout every 5th day. The specific interval exercise bouts were termed Gallop (n=13), Sprint (n=14) and Jump (n=13) and consisted of 4 times 90 s sessions each: Gallop were runs at the heart rate producing a blood lactate concentration (LA) of 4 mmol/l, Sprint were accelerations on the long-sides and decelerations in the short-sides of an arena, and Jump consisted of jumping obstacles of increasing height. Horses were submitted to 3 different standardised exercise tests (SET) before and after each CP: SETv4 (v4 is the speed at which a blood LA of 4 mmol/l is determined), SETjump (16 one jump obstacles in an elliptical course) and SETcourse (11 obstacles at the level of individually adjusted maximal degrees of difficulty). SETv4 showed that the v4 increased more in the Gallop (n=7) and Jump groups (n=7) than in the Sprint group (n=6). These results are based on fewer horses than the others because weather conditions did not allow for running this SET after the second period of conditioning. SETjump showed that blood LA and the level of fatigue estimated by the rider decreased after all interval type exercise bouts. A subjective fatigue score used by the rider in SETcourse improved regardless of the conditioning type of the horses, while their jumping technique improved with Gallop and Jump interval exercise only. Also the blood LA after SETcourse was lower after conditioning with Gallop and Jump interval exercise and the jumping technique improved according to an experienced independent observer in horses conditioned with Gallop, remained the same with Jump and decreased with Sprint interval exercise. In conclusion, all interval type exercise bouts examined improved parameters of fitness, but Gallop and Jump interval exercise improved more parameters than Sprint interval exercise bouts (v4, blood LA and fatigue level assessed by the rider after Gallop and Jump interval exercise; blood LA and fatigue level assessed by the rider after Sprint exercise), and Gallop as well as Jump interval exercise bouts improved the jumping technique too (as assessed by the rider and the independent observer for Gallop, and by the rider only after Jump interval exercise).

Soluble CD163, a marker of Kupffer cell activation, is related to portal hypertension in patients with liver cirrhosis

BACKGROUND

Activation of Kupffer cells may be involved in the pathogenesis of portal hypertension by release of vasoconstrictive substances and fibrosis due to co-activation of hepatic stellate cells.

AIM

To study soluble plasma (s) CD163, a specific marker of activated macrophages, as a biomarker for portal hypertension in patients with liver cirrhosis.

METHODS

We measured sCD163 concentration and the hepatic venous pressure gradient (HVPG) by liver vein catheterisation in 81 cirrhosis patients (Child-Pugh CP-A: n = 26, CP-B: n = 29, CP-C: n = 26) and 22 healthy subjects. We also measured their cardiac output (CO), cardiac index and systemic vascular resistance (SVR). Liver status was examined by Child-Pugh and MELD-score.

RESULTS

In cirrhosis, sCD163 concentration was nearly three times higher than in controls (4.7 ± 2.5 vs. 1.6 ± 0.5 mg/L, P < 0.001). sCD163 was also higher, as measured in steps by CP-score (P < 0.001). The HVPG rose steeply to an asymptote of 22 mmHg with sCD163 up to about 5 mg/L and not to higher values with higher sCD163. In a multivariate analysis, sCD163 was the only independent predictor of the HVPG but did not predict any of the systemic circulatory findings. sCD163 > 3.95 mg/L (upper normal limit) predicted HVPG ≥ 10 mmHg with a positive predictive value of 0.99.

CONCLUSIONS

Circulating sCD163 originating from activated Kupffer cells is increased in cirrhosis with increasing Child-Pugh score and with increasing HVPG, and it is an independent predictor for HVPG. These findings support a primary role of macrophage activation in portal hypertension, and may indicate a target for biological intervention.

Diagnostic and prognostic signatures from the small non-coding RNA transcriptome in prostate cancer

Prostate cancer (PCa) is the most frequent male malignancy and the second most common cause of cancer-related death in Western countries. Current clinical and pathological methods are limited in the prediction of postoperative outcome. It is becoming increasingly evident that small non-coding RNA (ncRNA) species are associated with the development and progression of this malignancy. To assess the diversity and abundance of small ncRNAs in PCa, we analyzed the composition of the entire small transcriptome by Illumina/Solexa deep sequencing. We further analyzed the microRNA (miRNA) expression signatures of 102 fresh-frozen patient samples during PCa progression by miRNA microarrays. Both platforms were cross-validated by quantitative reverse transcriptase-PCR. Besides the altered expression of several miRNAs, our deep sequencing analyses revealed strong differential expression of small nucleolar RNAs (snoRNAs) and transfer RNAs (tRNAs). From microarray analysis, we derived a miRNA diagnostic classifier that accurately distinguishes normal from cancer samples. Furthermore, we were able to construct a PCa prognostic predictor that independently forecasts postoperative outcome. Importantly, the majority of miRNAs included in the predictor also exhibit high sequence counts and concordant differential expression in Illumina PCa samples, supported by quantitative reverse transcriptase-PCR. Our findings provide miRNA expression signatures that may serve as an accurate tool for the diagnosis and prognosis of PCa.

Low cardiac output predicts development of hepatorenal syndrome and survival in patients with cirrhosis and ascites

OBJECTIVES

Recent studies suggest that cardiac dysfunction precedes development of the hepatorenal syndrome. In this follow-up study, we aimed to investigate the relation between cardiac and renal function in patients with cirrhosis and ascites and the impact of cardiac systolic function on survival.

PATIENTS AND DESIGN

Twenty-four patients with cirrhosis and ascites were included. Cardiac function was investigated by gated myocardial perfusion imaging (MPI) for assessment of cardiac index (CI) and cardiac volumes. The renal function was assessed by determination of glomerular filtration rate (GFR) and renal blood flow (RBF) and the patients were followed up for 12 months.

RESULTS

In patients with a CI below 1.5 l/min/m(2) on MPI, GFR was lower (39 (SD 24) vs 63 (SD 23) ml/min, p = 0.03), RBF was lower (352 (SD 232) vs 561 (SD 229) ml/min, p = 0.06), and serum creatinine was higher (130 (SD 46) vs 78 (SD 29) mumol/l, p<0.01). The number of patients who developed hepatorenal syndrome type 1 within 3 months was higher in the group with low CI than in the high CI group (43% vs 5%, p = 0.04). Patients with the lowest CI (N = 8) had significantly poorer survival at 3, 9, and 12 months compared to those with a higher CI (N = 16), p<0.05. In contrast, the Model for End-stage Liver Disease (MELD) score failed to predict mortality in these patients.

CONCLUSIONS

The development of renal failure and poor outcome in patients with advanced cirrhosis and ascites seem to be related to a cardiac systolic dysfunction. Other parameters may be more important than MELD score to predict prognosis.

Aberrations of HER2 and TOP2A Genes in Breast Cancer

Copy number changes in TOP2A are frequently observed in HER2 amplified breast cancers, and amplification of a whole amplicon containing both genes has been suggested as the underling mechanism. Here, we describe copy number changes of HER2 and TOP2A in two cell lines; one characterized by having amplification of both genes and the other by having amplification of HER2 and deletion of TOP2A. The characteristics are compared to findings in patients with invasive breast cancer.Material and methods: Fluorescence in situ hybridization (FISH) with HER2, TOP2A and centromere 17 (CEN-17) probes was performed on metaphases, interphases and cut sections from breast cancer cell lines. Paired HER2/CEN-17 and TOP2A/CEN-17 data was available from 649 patients from a previously published biomarker study (Knoop et al. J Clin Oncol 2005;23:7483-90).Results: The physical localization of FISH signals in metaphase spreads from cell lines showed that simultaneous amplification is not a simple co-amplification of a whole amplicon containing both genes. HER2 and TOP2A aberrations seem to be due to different mechanisms of amplifications. Most gene signals are translocated to abnormal marker chromosomes. HER2 genes but not TOP2A genes are present in tandem amplicons, leading to a higher HER2 ratio. This observation was confirmed by patient FISH data: 373 tumors (57%) had normal status for both genes. Among the 276 abnormal tumors, 67% had different HER2 and TOP2A status. Simultaneous amplification of both genes was found in 28% of the abnormal tumors (12% of all patients) while deletion of both genes was observed in 5% of the cases (2% of all patients). The average gene/reference ratio was significantly different: 5.0 for TOP2A but 7.2 for HER2 in the amplified tumors (P&lt;0.001; χ2-test). In the HER2 assay 398 (61%) of the 649 tumors had more than 4 gene signals per nucleus while only 96 (15%) of the tumors had more than 4 TOP2A signals per nucleus.Conclusion: In the majority of breast cancer patients, simultaneous aberration of HER2 and TOP2A is not explained by simple co-amplification. Amplification of the two genes may be caused by different mechanisms, leading to higher level of amplification for HER2 compared to TOP2A.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2119.

Polysomy of Chromosome 17 in Breast Cancer

Purpose: Polysomy of chromosome 17 is frequently described in breast cancer, but firm definition of polysomy is lacking. We have used normal breast tissue to define the ploidy levels in the truncated nuclei of cut sections based on standard cytogenetic definition of ploidy in whole nuclei. Data from patients with invasive breast cancer enrolled in a randomized clinical trial was used to investigate the effect of polysomy of centromere 17 on patient survival. (Ejlertsen B et al., Eur J Cancer 2007:43:877-84).Material and methods: Fluorescence in situ hybridization (FISH) with TOP2A/CEN-17 was performed on 120 normal breast specimens. Centromere 17 (CEN-17) measurements from matching HER2/CEN-17 and TOP2A/CEN-17 FISH data was available from 649 patients from a previously published biomarker study (Knoop A et. al., J Clin Oncol 2005;23:7483-90).Results: Two thirds of the tumors had an average number of CEN-17 signals below two and 10% had more than three average CEN-17 signals. Monosomy (&lt;1.25 CEN-17/nucleus) of centromere 17 was observed in 8% of the tumors, 60% of the samples were diploid (1.26-2.09 CEN-17/nucleus), 22% triploid (2.10-2.93 CEN-17/nucleus), 5% tetraploid (2.94-3.77 CEN-17/nucleus) and 5% of the tumors had higher ploidy level (&gt;3.78 CEN-17/nucleus). In the aneuploid tumors and especially in the highly polyploidy tumors, amplification is the most frequent event in the HER2 assay whereas deletions increased with the ploidy level in TOP2A assay. Increasing ploidy was associated with decreased overall survival (P=0.0001), but multivariate analysis showed that polyploidy was not an independent prognostic factor neither predictive for treatment outcome.Conclusion: Polysomy 17 is a rare event in tumor samples from patients, but correlate to HER2 amplification and TOP2A deletion. However, inclusion of a reference probe is necessary if deletions are to be revealed and to avoid false positive amplified cases with a high proportion of dividing cells or a doubling of the DNA content. Very high polyploidy is associated with poor survival but is not an independent prognostic factor when other prognostic factor are included in a multivariate analysis. In this large clinical study, polysomy 17 was neither an independent prognostic nor predictive marker.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4035.

Naloxone stimulation test in women with hypothalamic amenorrhea: a preliminary report

We researched the possibility of the induction of ovulation by means of chronic opioid receptor blockade in 4 women with hypothalamic amenorrhea. Daily 4 mg naloxone were given as a bolus injection intravenously. By means of continuous determination of LH, FSH, 17-beta-estradiol (E2) and progesterone as well as of sonographic folliculometry follicular growth and subsequent ovulation should have been proved. Neither we found alterations of the basal values of LH, FSH, E2 and progesterone, nor we observed a follicular growth. These results lead us to the conclusion to put a naloxone stimulation test before further therapy. In this way opioid mediated hypothalamic ovarian insufficiencies can be registered and a therapy optimum can be reached early.

The epidemiology of febrile reactions in haemodialysis

Febrile reactions were studied in 2 000 consecutive haemodialyses performed in 85 patients. A number of 219 febrile reactions were registered in 49 patients (11%). The overall month-to-month incidence showed little variation. Febrile reactions were not distributed randomly among the patients; those with respiratory tract infection experienced more febrile reactions during periods with infection than during periods without. Similarly, the incidence was higher in patients with than without chronic urinary tract infection. A low incidence was registered both in patients under 40 years of age and in patients having had more than 100 dialyses at the beginning of the observation period. The frequency was the same whether single-pass or recirculating single-pass monitors had been used, and it was not influenced by blood transfusions during dialysis. Thus, our analysis leads to the conclusion that the majority of the febrile reactions registered among the present patients were determined by endogenous factors such as infection, while exogenous factors such as dialysate bacteria and pyrogens seem to have played only a minor role.

Impact on regional recurrence and survival of axillary surgery in women with node-negative primary breast cancer

Background

This study examined whether axillary lymph node dissection (ALND) with removal of many normal lymph nodes resulted in a reduced rate of axillary recurrence and better survival, as reported in recent studies.

Methods

The follow-up analyses were based on 8657 patients with node-negative primary breast cancer treated solely by surgery. Median follow-up was 9 years.

Results

The number of lymph nodes removed correlated with a reduction in the rate of subsequent axillary recurrence (from 2·1 to 0·4 per cent; P = 0·037), local recurrence (from 7·4 to 3·8 per cent; P &lt; 0·001) distant metastases (from 15·0 to 10·3 per cent; P &lt; 0·001) and death as first event (from 7·5 to 5·5 per cent; P = 0·012).

Conclusion

When ALND is indicated, at least ten axillary lymph nodes should be retrieved. The role of ALND as primary treatment has decreased significantly during the past decade. The findings leave the concept of the sentinel node biopsy intact, as a highly specific procedure compared to ALND.

Chronic pain and other sequelae in long-term breast cancer survivors: nationwide survey in Denmark

OBJECTIVES

To investigate self-reported chronic pain and other sequelae in a nationally representative sample of long-term breast cancer survivors (BCS).

DESIGN

Age-stratified random sample of 2,000 female BCS 5 years after primary surgery without recurrence drawn from the Danish Breast Cancer Cooperative Group register, which is representative regarding long-term BCS in Denmark.

ASSESSMENT

Self-administered questionnaire including questions on sociodemography, chronic pain (6 months), health-related quality of life (HRQOL) and other sequelae related to breast cancer. Associations with treatment were investigated. Report of chronic pain was compared to normative data.

RESULTS

The response rate was 79%. Chronic pain prevalence of 42% was significantly higher in BCS compared to general population women (SRR: 1.32; 95% CI: 1.23-1.42). Sequelae related to breast cancer were paraesthesia 47%, chronic pain 29%, arm/shoulder swelling 25%, phantom sensations 19%, and allodynia 15%. Chronic pain related to breast cancer was significantly associated with poorer HRQOL and higher medicine consumption, and, in multiple logistic regression analysis, with age (<70 years), short education, being single (divorced, widowed, separated), radiotherapy, and time since operation <10 years. Radiotherapy and younger age were significantly associated with most sequelae.

CONCLUSION

Chronic pain was more prevalent in BCS compared to the general population. Significant predictors for sequelae related to breast cancer were radiotherapy and younger age. Future research should therefore prioritize sequelae prevention.

Treatment of acute variceal bleeding

The management of variceal bleeding remains a clinical challenge with a high mortality. Standardisation in supportive and new therapeutic treatments seems to have improved survival within the last 25 years. Although overall survival has improved in recent years, mortality is still closely related to failure to control initial bleeding or early re-bleeding occurring in up to 30-40% of patients. Initial procedures are to secure and protect the airway, and administer volume replacement to stabilize the patient. Treatment with vasoactive drugs should be started as soon as possible, since a reduction in portal pressure is associated with a better control of bleeding and may facilitate later endoscopic procedures. Vasopressin and its analogues Terlipressin and somatostatin and analogues are the two types of medicine, which has been evaluated. In meta-analysis, only Terlipressin have demonstrated effects on control of bleeding and on mortality. Somatostatin and its analogues improve control of bleeding, but show in meta-analysis no effects on mortality. Approximately 20% of patients with variceal bleeding will suffer from an infection, when they are hospitalized. Invasive procedures will further increase the risk of bacterial infections. Meta-analysis of clinical trials comparing antibiotics with placebo demonstrates that antibiotic prophylaxis improves survival with 9% (p<0.004). Quinolones or intravenous cephalosporins should be preferred. Early endoscopy should be performed in patients with major bleeding. Endoscopic therapy increases control of bleeding and decreases the risks of rebleeding and mortality. Ligation is probably more effective than sclerotherapy with fewer complications and should therefore be preferred, if possible. In case of gastric variceal bleeding, tissue adhesives should be used.

IN CONCLUSION

Improvements in resuscitation and prevention of complications have together with introduction of vasoactive drugs and refinement of endoscopic therapy majorily changed the prognosis of the patient presenting with variceal bleeding.

Treatment of acute variceal bleeding

The management of variceal bleeding remains a clinical challenge with a high mortality. Standardisation in supportive and new therapeutic treatments seems to have improved survival within the last 25 years. Although overall survival has improved in recent years, mortality is still closely related to failure to control initial bleeding or early re-bleeding occurring in up to 30-40% of patients. Initial procedures are to secure and protect the airway, and administer volume replacement to stabilize the patient. Treatment with vasoactive drugs should be started as soon as possible, since a reduction in portal pressure is associated with a better control of bleeding and may facilitate later endoscopic procedures. Vasopressin and its analogues Terlipressin and somatostatin and analogues are the two types of medicine, which has been evaluated. In meta-analysis, only Terlipressin have demonstrated effects on control of bleeding and on mortality. Somatostatin and its analogues improve control of bleeding, but show in meta-analysis no effects on mortality. Approximately 20% of patients with variceal bleeding will suffer from an infection, when they are hospitalized. Invasive procedures will further increase the risk of bacterial infections. Meta-analysis of clinical trials comparing antibiotics with placebo demonstrates that antibiotic prophylaxis improves survival with 9% (p<0.004). Quinolones or intravenous cephalosporins should be preferred. Early endoscopy should be performed in patients with major bleeding. Endoscopic therapy increases control of bleeding and decreases the risks of rebleeding and mortality. Ligation is probably more effective than sclerotherapy with fewer complications and should therefore be preferred, if possible. In case of gastric variceal bleeding, tissue adhesives should be used.

IN CONCLUSION

Improvements in resuscitation and prevention of complications have together with introduction of vasoactive drugs and refinement of endoscopic therapy majorily changed the prognosis of the patient presenting with variceal bleeding.

Cardiovascular complications of cirrhosis

Cardiovascular complications of cirrhosis include cardiac dysfunction and abnormalities in the central, splanchnic and peripheral circulation, and haemodynamic changes caused by humoral and nervous dysregulation. Cirrhotic cardiomyopathy implies systolic and diastolic dysfunction and electrophysiological abnormalities, an entity that is different from alcoholic heart muscle disease. Being clinically latent, cirrhotic cardiomyopathy can be unmasked by physical or pharmacological strain. Consequently, caution should be exercised in the case of stressful procedures, such as large volume paracentesis without adequate plasma volume expansion, transjugular intrahepatic portosystemic shunt (TIPS) insertion, peritoneovenous shunting and surgery. Cardiac failure is an important cause of mortality after liver transplantation, but improved liver function has also been shown to reverse the cardiac abnormalities. No specific treatment can be recommended, and cardiac failure should be treated as in non-cirrhotic patients with sodium restriction, diuretics, and oxygen therapy when necessary. Special care should be taken with the use of ACE inhibitors and angiotensin antagonists in these patients. The clinical significance of cardiovascular complications and cirrhotic cardiomyopathy is an important topic for future research, and the initiation of new randomised studies of potential treatments for these complications is needed.

Cardiovascular complications of cirrhosis

Cardiovascular complications of cirrhosis include cardiac dysfunction and abnormalities in the central, splanchnic and peripheral circulation, and haemodynamic changes caused by humoral and nervous dysregulation. Cirrhotic cardiomyopathy implies systolic and diastolic dysfunction and electrophysiological abnormalities, an entity that is different from alcoholic heart muscle disease. Being clinically latent, cirrhotic cardiomyopathy can be unmasked by physical or pharmacological strain. Consequently, caution should be exercised in the case of stressful procedures, such as large volume paracentesis without adequate plasma volume expansion, transjugular intrahepatic portosystemic shunt (TIPS) insertion, peritoneovenous shunting and surgery. Cardiac failure is an important cause of mortality after liver transplantation, but improved liver function has also been shown to reverse the cardiac abnormalities. No specific treatment can be recommended, and cardiac failure should be treated as in non-cirrhotic patients with sodium restriction, diuretics, and oxygen therapy when necessary. Special care should be taken with the use of ACE inhibitors and angiotensin antagonists in these patients. The clinical significance of cardiovascular complications and cirrhotic cardiomyopathy is an important topic for future research, and the initiation of new randomised studies of potential treatments for these complications is needed.

Q-T interval (QT(C)) in patients with cirrhosis: relation to vasoactive peptides and heart rate

OBJECTIVE

Prolonged Q-T interval (QT) has been reported in patients with cirrhosis who also exhibit profound abnormalities in vasoactive peptides and often present with elevated heart rate (HR). The aim of this study was to relate QT to the circulating level of endothelins (ET-1 and ET-3) and calcitonin gene-related peptide (CGRP) in patients with cirrhosis. In addition, we studied problems with HR correction of QT.

MATERIAL AND METHODS

Forty-eight patients with cirrhosis and portal hypertension were studied during a haemodynamic investigation. Circulating levels of ETs and CGRP were determined by radioimmunoassays. Correction of QT for HR above 60 beats per min was performed using the methods described by Bazett (QT(C)) and Fridericia (QT(F)).

RESULTS

Prolonged QT(C) (above 440 ms), found in 56% of the patients, was related to the presence of significant portal hypertension and liver dysfunction (p < 0.05 to 0.001), but not to elevated ET-1, ET-3 or CGRP. When corrected according to Bazett, QT(C) showed no significant relation to differences in HR between patients (r = 0.07, ns). QTF showed some undercorrection of HR (r = -0.36; p < 0.02). During HR variation in the individual patient, QT(C) revealed a small but significant overcorrection (2.6 ms per heartbeat per min; p < 0.001). This value was significantly (p < 0.02) smaller with QTF (1.2 ms per heartbeat per min).

CONCLUSIONS

The prolonged QT(C) in cirrhosis is related to liver dysfunction and the presence of portal hypertension, but not to the elevated powerful vasoconstrictor (ET-1) or vasodilator (CGRP, ET-3) peptides. The problems with correction of the QT for elevated HR in cirrhosis are complex, and the lowest HR should be applied for determination of the QT.

Axillary staging during surgery for breast cancer

Background

Axillary lymph node status remains the single most important prognostic parameter in patients with breast cancer. In approximately half of operations sentinel lymph node biopsy cannot be employed and axillary dissection is indicated. Retrieval of ten nodes has hitherto been considered sufficient, but it remains questionable whether the removal of more lymph nodes might improve staging.

Methods

Data from 31 679 breast cancer operations in Denmark were analysed.

Results

The number of axillary lymph nodes retrieved was an independent and strong predictor of node positivity. The more lymph nodes retrieved, the better the staging of the disease; this was evident for all sizes of tumour. Dissection of 20 or more nodes rather than ten to 14 increased the probability of node positivity from 14·2 to 25·9 per cent for 1–5-mm tumours, from 38·6 to 47·9 per cent for 11–20-mm tumours, and from 80·6 to 90·0 per cent for tumours with diameter greater than 50 mm.

Conclusion

The number of metastatic lymph nodes increased as more nodes were retrieved. These findings underline the need for high-quality specialist surgical and pathological services in breast cancer treatment.

Dietary fatty acid composition rather than vitamin E supplementation influence ex vivo cytokine and eicosanoid response of porcine alveolar macrophages

This study examined the influence of different dietary fat sources (animal fat, sunflower oil, and fish oil) and supplementation of vitamin E (85, 150 and 300 mg all-rac-alpha-tocopheryl acetate/kg diet) on the ex vivo synthesis of eicosanoids and cytokines by porcine alveolar macrophages. Supplementation of vitamin E provoked an increase in the concentration of alpha-tocopherol of the macrophages irrespective of fat sources. Fish oil increased the macrophage n-3 content with 100% and 40%, and reduced the n-6 with 60% and 53% in comparison with sunflower oil and animal fat, respectively. Fish oil decreased the production of TNF-alpha, IL-8, LTB4, and PGE2 (but not IL-6) relative to the other dietary fat sources, and no difference was observed between sunflower oil and animal fat. Positive correlations were found between the n-6 fatty acid content and the production of PGE2, and the PGE2 production was positively correlated with TNF-alpha and IL-8. Negative correlations were found between the n-3 PUFA content and the concentration of PGE2, TNF-alpha and IL-8. In conclusion, dietary fish oil supplemented at a level of 5%, but not supplemental vitamin E, influenced the inflammatory responses of alveolar macrophages isolated from weaned pigs relatively to animal fat and sunflower oil.

The multifunctional roles of the four-and-a-half-LIM only protein FHL2

Numerous cellular processes require the concerted action of multiple proteins that assemble in functional complexes. Protein-protein interaction domains allow specific proteins to combine with certain partners. Specificity of protein-protein association can be obtained by an interaction code predicted by conserved amino acid sequences. One of the protein-protein interaction motifs is the LIM domain, a conserved cysteine-rich module present in more than 100 different human proteins. The human four-and-a-half-LIM-only protein family consists of the members FHL1, FHL2, FHL3, FHL4 and ACT. They are expressed in a cell- and tissue-specific manner and participate in various cellular processes, including regulation of cell survival, transcription and signal transduction. Here, we review the current knowledge of the best-studied member of this family, FHL2. We describe the transcription regulation, the expression profile, the interaction partners, the subcellular localization, the biological functions and discuss the possible involvement of FHL2 in human diseases.

Arterial hypertension in cirrhosis: arterial compliance, volume distribution, and central haemodynamics

BACKGROUND AND AIMS

Arterial hypertension is a common disorder. Hyperkinetic circulation and reduced effective volaemia are central elements in the haemodynamic dysfunction in cirrhosis. The aim of the present study was to investigate whether cirrhotic patients with arterial hypertension are normokinetic and normovolaemic or whether they reveal the same circulatory dysfunction as their normotensive counterparts.

MATERIAL AND METHODS

Thirty three patients with arterial hypertension were identified among 648 patients with cirrhosis: 14 in Child class A, 12 in class B, and seven in class C. Controls were 130 normotensive cirrhotic patients, 19 controls with normal arterial blood pressure and without liver disease, and 16 patients with essential arterial hypertension. All groups underwent haemodynamic investigation with determination of cardiac output (CO), plasma volume (PV), central blood volume (CBV), hepatic venous pressure gradient (HVPG), hepatic blood flow (HBF), arterial compliance (AC), and systemic vascular resistance (SVR) in the supine position.

RESULTS

Liver function, as evaluated by galactose elimination capacity, indocyanine green clearance, HBF, and Child score, was significantly better in hypertensive cirrhotics than in their normotensive counterparts (p<0.05-0.01) but portal pressure was similar (HVPG 13 v 15 mm Hg; NS). AC was significantly lower and normal in the arterial hypertensive cirrhotic group (1.07 v 1.39 mm Hg/ml; p<0.02) and SVR was significantly higher and normal (1475 v 1020 dynxs/cm5; p<0.01). Arterial hypertensive cirrhotic patients were hyperdynamic (CO 6.80 v 7.14 l/min; NS) and central hypovolaemic (CBV 19.8 v 20.6 ml/kg; NS), as were normotensive patients, but differences were found in relation to arterial blood pressure. Whereas arterial pressure was inversely correlated with CO, PV, and Child score in the normotensive group (p< 0.01), the same correlations were either direct or insignificant in arterial hypertensive cirrhotics.

CONCLUSION

Arterial hypertensive cirrhotic patients are hyperkinetic and central hypovolaemic, in common with their normotensive counterparts, but vasodilatation is reduced and regulation of arterial blood pressure may be less deranged.

BNP and N-terminal proBNP are both extracted in the normal kidney

BACKGROUND

Increased plasma concentrations of cardiac-derived B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (proBNP) are both associated with left ventricular dysfunction. Information on the regional elimination of the peptides is, however, still scarce. We therefore examined the renal and peripheral extraction of N-terminal proBNP and BNP.

MATERIALS AND METHODS

The study comprised 18 patients with essential arterial hypertension, 51 with cirrhosis, and 18 control patients without kidney or liver disease. All patients underwent a haemodynamic investigation with catheterization of the femoral artery and femoral and renal veins. Blood sampling from the catheters allowed determination of the arteriovenous extraction ratio of N-terminal proBNP and BNP.

RESULTS

Neither the peripheral N-terminal proBNP (13, 11, 19 pmol L(-1), NS) nor the BNP plasma concentrations (4, 12, 9 pmol L(-1), NS) differed between the patient groups. In addition, similar renal extractions were observed in the groups. The renal extraction of N-terminal proBNP (0.16) was not different from that of BNP (0.16). In contrast, the N-terminal proBNP extraction in the lower extremity was markedly lower compared with BNP (0.00 vs. 0.125, P = 0.007).

CONCLUSIONS

A comparable renal elimination of N-terminal proBNP and BNP is contrasted by a selective extraction of BNP in the lower extremity. Our results suggest a different elimination mechanism in the renal and peripheral circulation, which partly may explain the higher N-terminal proBNP compared with BNP concentrations in normal plasma.

Radiation-induced upregulation of gamma-glutamyltransferase in colon carcinoma cells is mediated through the Ras signal transduction pathway

The activity of gamma-glutamyltransferase (GGT) is frequently upregulated in tumor cells after oxidative stress and may thus increase the availability of amino acids needed for biosynthesis of the antioxidant glutathione. As gamma-radiation of tumor cells can result in oxidative stress, we investigated whether such treatments modulate the enzyme level in colon carcinoma CC531 cells. Radiation of these cells blocked cell proliferation, increased cellular size, initiated apoptosis and upregulated GGT activity and protein levels in a dose- and time-related manner. A slight but significant increase in the cellular level of reactive oxygen species (ROS) was found directly after radiation but appeared not to cause the GGT elevation. Thus, other mechanisms than cellular oxidative stress appear to be responsible for the radiation-induced upregulation of GGT. Stable transfection of activated Ras in a human colon carcinoma cell line expressing wild-type Ras resulted in an increased GGT level, while a reduced enzyme level was demonstrated in another cell line with constitutively activated Ras after stably transfection with a dominant-negative Ras mutant. Moreover, addition of specific protein kinase inhibitors that blocked downstream targets PI-3K and MEK1/2 of Ras, prior to and after radiation, attenuated the radiation-induced activation of GGT. These results support a role for Ras, being frequently activated after radiation, in regulating the level of GGT and also indicate that GGT participates in radioresistance.

Does timing of adjuvant chemotherapy influence the prognosis after early breast cancer? Results of the Danish Breast Cancer Cooperative Group (DBCG)

The purpose of this study was to examine the effect on survival of delaying the start of adjuvant chemotherapy for early breast cancer for up to 3 months after surgery. In the nation-wide clinical trials of the Danish Breast Cancer Cooperative Group, 7501 breast cancer patients received chemotherapy within 3 months of surgery between 1977 and 1999: 352 with classical cyclofosfamide, metotrexate and 5-fluorouracil (CMF); 6065 with CMF i.v. and 1084 with cyclofosfamide, epirubicin and 5-fluorouracil. For the analysis, the time between surgery and the start of chemotherapy was divided into four strata (1–3, 4, 5 and 6–13 weeks). The results show that within the three groups of chemotherapy, there was an even distribution of known prognostic factors across the four strata of initiation of chemotherapy. There was no pattern indicating a benefit from early start of chemotherapy. No significant interactions were found for subgroups of patients with a poorer prognosis (many involved lymph nodes, high-grade malignancies or hormone receptor negative disease). In conclusion, we have found no evidence for a survival benefit due to early initiation of adjuvant chemotherapy within the first 2–3 months after surgery.

Arterial hypertension and chronic liver disease

This review looks at the alterations in the systemic haemodynamics of patients with chronic liver disease (cirrhosis) in relation to essential hypertension and arterial hypertension of renal origin. Characteristic findings in patients with cirrhosis are vasodilatation with low overall systemic vascular resistance, high arterial compliance, increased cardiac output, secondary activation of counterregulatory systems (renin-angiotensin-aldosterone system, sympathetic nervous system, release of vasopressin), and resistance to vasopressors. The vasodilatory state is mediated through adrenomedullin, calcitonin gene-related peptide, nitric oxide, and other vasodilators, and is most pronounced in the splanchnic area. This provides an effective (although relative) counterbalance to raised arterial blood pressure. Subjects with arterial hypertension (essential, secondary) may become normotensive during the development of chronic liver disease, and arterial hypertension is rarely manifested in patients with cirrhosis, even in those with renovascular disease and high circulating renin activity. There is much dispute as to the understanding of homoeostatic regulation in cirrhotic patients with manifest arterial hypertension. This probably includes the combination of vasodilatation and vasoconstriction in parallel.

Breast cancer with different prognostic characteristics developing in Danish women using hormone replacement therapy

The aim of this study is to investigate the risk of developing prognostic different types of breast cancer in women using hormone replacement therapy (HRT). A total of 10 874 postmenopausal Danish Nurses were followed since 1993. Incident breast cancer cases and histopathological information were retrieved through the National Danish registries. The follow-up ended on 31 December 1999. Breast cancer developed in 244 women, of whom 172 were invasive ductal carcinomas. Compared to never users, current users of HRT had an increased risk of a hormone receptor-positive breast cancer, but a neutral risk of receptor-negative breast cancer, relative risk (RR) 3.29 (95% confidence interval (CI): 2.27–4.77) and RR 0.99 (95% CI: 0.42–2.36), respectively (P for difference=0.013). The risk of being diagnosed with low histological malignancy grade was higher than high malignancy grade with RR 4.13 (95% CI: 2.43–7.01) and RR 2.17 (95% CI: 1.42–3.30), respectively (P=0.063). For breast cancers with other prognostic characteristics, the risk was increased equally for the favourable and nonfavourable types. Current users of HRT experience a two- to four-fold increased risk of breast cancer with various prognostic characteristics, both the favourable and nonfavourable types. For receptor status, the risk with HRT was statistically significantly higher for hormone receptor-positive breast cancer compared to receptor-negative breast cancer.

Review article: pathogenesis and pathophysiology of hepatorenal syndrome--is there scope for prevention?

The hepatorenal syndrome (HRS) is a functional impairment of the kidneys in chronic liver disease caused by a circulatory failure. The prognosis is poor, particularly with type 1 HRS, but also type 2, and only liver transplantation is of lasting benefit. However, recent research into the pathophysiology of ascites and HRS has stimulated new enthusiasm in their prevention and treatment. Patients with HRS have hyperdynamic circulatory dysfunction with reduced arterial blood pressure and reduced central blood volume, owing to preferential splanchnic arterial vasodilatation. Activation of potent vasoconstricting systems, including the sympathetic nervous and renin-angiotensin-aldosterone systems, counteracts the arterial vasodilatation and leads to a pronounced renal vasoconstriction with renal hypoperfusion, a reduced glomerular filtration rate, and intense sodium-water retention. Thus prevention of HRS should seek to improve liver function, limit arterial hypotension and central hypovolaemia, and reduce renal vasoconstriction and the renal and interstitial pressures. Portal pressure can be reduced with beta-adrenergic blockers and transjugular intrahepatic portosystemic shunt (TIPS). Precipitating events, like infections, bleeding, and postparacentesis circulatory syndrome, should be treated to avoid further circulatory failure. Improvement in arterial blood pressure and central hypovolaemia can be achieved with vasoconstrictors, such as terlipressin (Glypressin), and plasma expanders such as human albumin. In the future endothelins, adenosine antagonists, long-acting vasoconstrictors, and antileukotriene drugs may play a role in preventing and treating HRS.

Effect of terlipressin on blood volume distribution in patients with cirrhosis

BACKGROUND

Patients with cirrhosis and portal hypertension have an altered blood volume distribution and a hyperdynamic systemic circulation. Terlipressin is known to reduce portal pressure by decreasing splanchnic inflow, but its effect on the blood volume distribution is unknown. The aim of the study was to investigate changes in regional blood volume distribution and systemic haemodynamics after administration of terlipressin to patients with cirrhosis.

METHODS

Blood volume distribution was determined in 13 patients with cirrhosis and portal hypertension by a dual-head gamma-camera technique and systemic haemodynamics was measured before and after intravenous administration of terlipressin (2 mg).

RESULTS

Terlipressin increased the blood volume in the thorax region (+6.0%, P < 0.002) and the liver region (+12.2%, P < 0.002), whereas blood volume in the splanchnic region remained unchanged. Systemic vascular resistance (SVR) and mean arterial blood pressure increased after terlipressin (+34 and +21%, P < 0.001). The increase in liver blood volume correlated directly with the increase in SVR (r = 0.88. P < 0.001).

CONCLUSIONS

Terlipressin ameliorates the hyperdynamic circulation, increases thorax and liver blood volumes, but produces no effect on the splanchnic blood volume. Besides decreasing the splanchnic inflow, terlipressin may affect portal pressure by causing vasodilatation of intrahepatic vessels.

Dysphonia: medical treatment and a medical voice hygiene advice approach. A prospective randomised pilot study

For many years all patients with dysphonia referred to in the literature as resulting from non-organic (functional) voice disorders were sent to speech therapy. Medical diagnoses were not taken into account. In our earlier Cochrane review on vocal cord nodules we discovered that evidence-based research in the area of benign voice disorders with dysphonia, and with or without slight benign swellings including nodules on the vocal cords, was lacking at that time. Therefore, a prospective randomised pilot study based on our Cochrane review has been made on dysphonic patients with non-organic (function provoked?) voice disorders as the basis for further evidence-based studies. Medical treatment was based on the scientific approach that once a micro-organic disorder caused by reflux, infection, allergy or environmental irritatants (e.g., dust or noise in the workplace) was discovered by very careful anamnesis and systematic objective routine analyses and was treated effectively, with documentation, the non-organic voice disorder disappeared, as, e.g., in the case of a diagnosis and treatment of helicobakter pylori. The reason is that the mucosal swelling/dysfunction of the vocal cords is secondary. In order to try to understand why the recommendation to all these patients for many years was only voice therapy, which the speech therapists "felt to be effective", updated voice-hygiene advice (for posture, accents of the diaphragm, intonation pattern and resonance) was given by experienced laryngologists, randomised with the updated medical diagnosis/therapy in order to elucidate what effect the training might have. No evidence-based studies in the literature document any effect. The crucial point seemed to be that doctors mostly did not examine any other diagnoses other than the "dysphonia" and did not dig down to any of the medical reasons when the vocal fold diagnosis of "non- organic disorders" was made. This should be changed in the future. This pilot study was based on a comparison of ten dysphonic patients with stroboscopic non- organic (functional) voice disorders, where a micro-organic diagnosis was searched for and treated systematically in a medical regime (for infections, allergies, gastrooesophageal reflux and environmental irritants such as dust, noise, etc.) versus ten dysphonic patients with stroboscopically confirmed non-organic (functional) voice disorders, having only the traditional but optimal voice advice, which we can call medical voice-hygiene advice, including the use of the Accent method. A retrospective group of ten patients treated medically was included, too. A demand cannot be made that the functional group being treated by randomisation with voice advice should also be medically treated at once, the medical approach being the new one. On the other hand, it is strange that no evidence-based research was made before. All patients were measured two times with stored videostroboscopy, a quality-of-life questionnaire and phonetograms with 1-month intervals. All patient groups improved. There was no statistical improvement in favour of the medical group with the voice-related quality-of-life score, also not for the group who received voice-hygiene advice. The geometrical mean values of the phonetogram areas in decibels times semitones were better in all groups, but a statistical difference was not found between the medically treated group and the voice-hygiene advice group. The pilot study showed that both medical treatment and medical voice-hygiene advice had a positive effect on dysphonia in non-organic (functional) voice disorders. There is need of an extensive prospective randomised trial on dysphonia including vocal cord nodules to find out which treatment should be used for this group of patients. It is suggested that an eventual randomisation for microsurgical treatment or regular voice therapy should be made after a period of systematic medical diagnosis and treatment including medical voice-hygiene advice.